|
BRA MASTECTOMY KIT MEDEBRA SMALL 32-34 IN A-C MEDEKIT-001W
|
Facility
|
IP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$273.66 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$335.09
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA MASTECTOMY KIT MEDEBRA SMALL 32-34 IN A-C MEDEKIT-001W
|
Facility
|
OP
|
$537.00
|
|
|
Service Code
|
HCPCS L8015
|
| Hospital Charge Code |
5611554
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$513.80 |
| Rate for Payer: Aetna Commercial |
$502.63
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$480.29
|
| Rate for Payer: Aetna Managed Medicare |
$156.37
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46.37
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$46.37
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$46.37
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$295.99
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cash Price |
$161.10
|
| Rate for Payer: Cigna Commercial |
$513.80
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$312.53
|
| Rate for Payer: Health EOS Commercial |
$497.05
|
| Rate for Payer: HFN Commercial |
$513.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$418.86
|
| Rate for Payer: Multiplan Commercial |
$446.78
|
| Rate for Payer: NAPHCARE Commercial |
$335.09
|
| Rate for Payer: Preferred Network Access Commercial |
$513.80
|
| Rate for Payer: Quartz Beloit One Network |
$273.66
|
| Rate for Payer: Quartz Commercial |
$363.01
|
| Rate for Payer: Quartz Medicare Advantage |
$335.09
|
| Rate for Payer: The Alliance Commercial |
$307.05
|
| Rate for Payer: WEA Trust Commercial |
$307.16
|
| Rate for Payer: WPS Commercial |
$413.65
|
|
|
BRA SURGICAL SUPPORT CHEST LARGE FITS 40 M5001-L
|
Facility
|
IP
|
$390.00
|
|
| Hospital Charge Code |
2975054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST LARGE FITS 40 M5001-L
|
Facility
|
OP
|
$390.00
|
|
| Hospital Charge Code |
2975054
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.57 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Aetna Managed Medicare |
$113.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.98
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.20
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: NAPHCARE Commercial |
$243.36
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$263.64
|
| Rate for Payer: Quartz Medicare Advantage |
$243.36
|
| Rate for Payer: The Alliance Commercial |
$202.80
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST MEDIUM FITS 36 M5001-M
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975053
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Aetna Managed Medicare |
$113.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.98
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.20
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: NAPHCARE Commercial |
$243.36
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$263.64
|
| Rate for Payer: Quartz Medicare Advantage |
$243.36
|
| Rate for Payer: The Alliance Commercial |
$216.86
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST MEDIUM FITS 36 M5001-M
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975053
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST X-LARGE FITS 44 M5001-XL
|
Facility
|
IP
|
$390.00
|
|
| Hospital Charge Code |
2975055
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST X-LARGE FITS 44 M5001-XL
|
Facility
|
OP
|
$390.00
|
|
| Hospital Charge Code |
2975055
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$113.57 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Aetna Managed Medicare |
$113.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$263.64
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$202.80
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$194.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.98
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.20
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: NAPHCARE Commercial |
$243.36
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$263.64
|
| Rate for Payer: Quartz Medicare Advantage |
$243.36
|
| Rate for Payer: The Alliance Commercial |
$202.80
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST XX-LARGE FITS 48 M5001-XXL
|
Facility
|
OP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975056
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$29.83 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Aetna Managed Medicare |
$113.57
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$29.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$29.83
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$29.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$226.98
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$304.20
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: NAPHCARE Commercial |
$243.36
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$263.64
|
| Rate for Payer: Quartz Medicare Advantage |
$243.36
|
| Rate for Payer: The Alliance Commercial |
$216.86
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRA SURGICAL SUPPORT CHEST XX-LARGE FITS 48 M5001-XXL
|
Facility
|
IP
|
$390.00
|
|
|
Service Code
|
HCPCS L8000
|
| Hospital Charge Code |
2975056
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$198.74 |
| Max. Negotiated Rate |
$373.15 |
| Rate for Payer: Aetna Commercial |
$365.04
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$348.82
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$214.97
|
| Rate for Payer: Cash Price |
$117.00
|
| Rate for Payer: Cigna Commercial |
$373.15
|
| Rate for Payer: Health EOS Commercial |
$360.98
|
| Rate for Payer: HFN Commercial |
$373.15
|
| Rate for Payer: Multiplan Commercial |
$324.48
|
| Rate for Payer: Preferred Network Access Commercial |
$373.15
|
| Rate for Payer: Quartz Beloit One Network |
$198.74
|
| Rate for Payer: Quartz Commercial |
$243.36
|
| Rate for Payer: WEA Trust Commercial |
$223.08
|
| Rate for Payer: WPS Commercial |
$300.42
|
|
|
BRAVO PH REFLEX PROCEDURE
|
Facility
|
OP
|
$3,212.00
|
|
| Hospital Charge Code |
5404670
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$935.33 |
| Max. Negotiated Rate |
$3,073.24 |
| Rate for Payer: Aetna Commercial |
$3,006.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,872.81
|
| Rate for Payer: Aetna Managed Medicare |
$935.33
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,171.31
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$1,670.24
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,603.43
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,770.45
|
| Rate for Payer: Cash Price |
$963.60
|
| Rate for Payer: Cigna Commercial |
$3,073.24
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,869.38
|
| Rate for Payer: Health EOS Commercial |
$2,973.03
|
| Rate for Payer: HFN Commercial |
$3,073.24
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$2,505.36
|
| Rate for Payer: Multiplan Commercial |
$2,672.38
|
| Rate for Payer: NAPHCARE Commercial |
$2,004.29
|
| Rate for Payer: Preferred Network Access Commercial |
$3,073.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,636.84
|
| Rate for Payer: Quartz Commercial |
$2,171.31
|
| Rate for Payer: Quartz Medicare Advantage |
$2,004.29
|
| Rate for Payer: The Alliance Commercial |
$1,670.24
|
| Rate for Payer: WEA Trust Commercial |
$1,837.26
|
| Rate for Payer: WPS Commercial |
$2,474.20
|
|
|
BRAVO PH REFLEX PROCEDURE
|
Facility
|
IP
|
$3,212.00
|
|
| Hospital Charge Code |
5404670
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,636.84 |
| Max. Negotiated Rate |
$3,073.24 |
| Rate for Payer: Aetna Commercial |
$3,006.43
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,872.81
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,770.45
|
| Rate for Payer: Cash Price |
$963.60
|
| Rate for Payer: Cigna Commercial |
$3,073.24
|
| Rate for Payer: Health EOS Commercial |
$2,973.03
|
| Rate for Payer: HFN Commercial |
$3,073.24
|
| Rate for Payer: Multiplan Commercial |
$2,672.38
|
| Rate for Payer: Preferred Network Access Commercial |
$3,073.24
|
| Rate for Payer: Quartz Beloit One Network |
$1,636.84
|
| Rate for Payer: Quartz Commercial |
$2,004.29
|
| Rate for Payer: WEA Trust Commercial |
$1,837.26
|
| Rate for Payer: WPS Commercial |
$2,474.20
|
|
|
BRCA1,BRCA2
|
Facility
|
OP
|
$2,534.00
|
|
|
Service Code
|
CPT 81163
|
| Hospital Charge Code |
4500681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$486.72 |
| Max. Negotiated Rate |
$2,424.53 |
| Rate for Payer: Aetna Commercial |
$2,371.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,266.41
|
| Rate for Payer: Aetna Managed Medicare |
$486.72
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,825.20
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$851.76
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$807.96
|
| Rate for Payer: Anthem Medicare Advantage |
$486.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,396.74
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$486.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$486.72
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cigna Commercial |
$2,424.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$486.72
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,474.79
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$486.72
|
| Rate for Payer: Health EOS Commercial |
$2,345.47
|
| Rate for Payer: HFN Commercial |
$2,424.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,810.60
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$486.72
|
| Rate for Payer: Independent Care Health Plan Medicare |
$486.72
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$486.72
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$486.72
|
| Rate for Payer: Multiplan Commercial |
$2,108.29
|
| Rate for Payer: NAPHCARE Commercial |
$730.08
|
| Rate for Payer: Preferred Network Access Commercial |
$2,424.53
|
| Rate for Payer: Quartz Beloit One Network |
$1,291.33
|
| Rate for Payer: Quartz Commercial |
$1,712.98
|
| Rate for Payer: Quartz Medicare Advantage |
$486.72
|
| Rate for Payer: The Alliance Commercial |
$1,946.88
|
| Rate for Payer: United Healthcare Medicare Advantage |
$486.72
|
| Rate for Payer: United Healthcare PPO |
$1,976.52
|
| Rate for Payer: WEA Trust Commercial |
$1,449.45
|
| Rate for Payer: Wellcare Medicare |
$486.72
|
| Rate for Payer: WPS Commercial |
$1,951.94
|
|
|
BRCA1,BRCA2
|
Facility
|
IP
|
$2,534.00
|
|
|
Service Code
|
CPT 81163
|
| Hospital Charge Code |
4500681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,291.33 |
| Max. Negotiated Rate |
$2,424.53 |
| Rate for Payer: Aetna Commercial |
$2,371.82
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,266.41
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,396.74
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cigna Commercial |
$2,424.53
|
| Rate for Payer: Health EOS Commercial |
$2,345.47
|
| Rate for Payer: HFN Commercial |
$2,424.53
|
| Rate for Payer: Multiplan Commercial |
$2,108.29
|
| Rate for Payer: Preferred Network Access Commercial |
$2,424.53
|
| Rate for Payer: Quartz Beloit One Network |
$1,291.33
|
| Rate for Payer: Quartz Commercial |
$1,581.22
|
| Rate for Payer: WEA Trust Commercial |
$1,449.45
|
| Rate for Payer: WPS Commercial |
$1,951.94
|
|
|
BRCA1,BRCA2
|
Professional
|
Both
|
$2,534.00
|
|
|
Service Code
|
CPT 81163
|
| Hospital Charge Code |
4500681
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$486.72 |
| Max. Negotiated Rate |
$2,503.59 |
| Rate for Payer: Aetna Commercial |
$2,503.59
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$2,266.41
|
| Rate for Payer: Aetna Managed Medicare |
$486.72
|
| Rate for Payer: Anthem Medicare Advantage |
$486.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$486.72
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$486.72
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: Cigna Commercial |
$2,503.59
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$1,317.68
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$486.72
|
| Rate for Payer: Health EOS Commercial |
$2,398.18
|
| Rate for Payer: HFN Commercial |
$2,503.59
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,718.12
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,718.12
|
| Rate for Payer: Independent Care Health Plan Medicare |
$486.72
|
| Rate for Payer: Multiplan Commercial |
$2,108.29
|
| Rate for Payer: NAPHCARE Commercial |
$730.08
|
| Rate for Payer: Preferred Network Access Commercial |
$2,503.59
|
| Rate for Payer: Quartz Beloit One Network |
$1,159.56
|
| Rate for Payer: Quartz Commercial |
$1,502.16
|
| Rate for Payer: Quartz Medicare Advantage |
$486.72
|
| Rate for Payer: The Alliance Commercial |
$1,922.54
|
| Rate for Payer: United Healthcare Medicare Advantage |
$486.72
|
| Rate for Payer: WEA Trust Commercial |
$1,449.45
|
| Rate for Payer: WPS Commercial |
$2,141.57
|
|
|
BRCAvantage, Comprehensive
|
Professional
|
Both
|
$5,039.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
4500577
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,897.88 |
| Max. Negotiated Rate |
$8,350.65 |
| Rate for Payer: Aetna Commercial |
$4,978.53
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,506.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,897.88
|
| Rate for Payer: Anthem Medicare Advantage |
$1,897.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,897.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,897.88
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,978.53
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$2,620.28
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,897.88
|
| Rate for Payer: Health EOS Commercial |
$4,768.91
|
| Rate for Payer: HFN Commercial |
$4,978.53
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$6,699.50
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$6,699.50
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,897.88
|
| Rate for Payer: Multiplan Commercial |
$4,192.45
|
| Rate for Payer: NAPHCARE Commercial |
$2,846.81
|
| Rate for Payer: Preferred Network Access Commercial |
$4,978.53
|
| Rate for Payer: Quartz Beloit One Network |
$2,305.85
|
| Rate for Payer: Quartz Commercial |
$2,987.12
|
| Rate for Payer: Quartz Medicare Advantage |
$1,897.88
|
| Rate for Payer: The Alliance Commercial |
$7,496.61
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,897.88
|
| Rate for Payer: WEA Trust Commercial |
$2,882.31
|
| Rate for Payer: WPS Commercial |
$8,350.65
|
|
|
BRCAvantage, Comprehensive
|
Facility
|
IP
|
$5,039.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
4500577
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2,567.87 |
| Max. Negotiated Rate |
$4,821.32 |
| Rate for Payer: Aetna Commercial |
$4,716.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,506.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,777.50
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,821.32
|
| Rate for Payer: Health EOS Commercial |
$4,664.10
|
| Rate for Payer: HFN Commercial |
$4,821.32
|
| Rate for Payer: Multiplan Commercial |
$4,192.45
|
| Rate for Payer: Preferred Network Access Commercial |
$4,821.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,567.87
|
| Rate for Payer: Quartz Commercial |
$3,144.34
|
| Rate for Payer: WEA Trust Commercial |
$2,882.31
|
| Rate for Payer: WPS Commercial |
$3,881.54
|
|
|
BRCAvantage, Comprehensive
|
Facility
|
OP
|
$5,039.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
4500577
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$1,897.88 |
| Max. Negotiated Rate |
$7,591.50 |
| Rate for Payer: Aetna Commercial |
$4,716.50
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$4,506.88
|
| Rate for Payer: Aetna Managed Medicare |
$1,897.88
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$7,117.03
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$3,321.28
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$3,150.47
|
| Rate for Payer: Anthem Medicare Advantage |
$1,897.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,777.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$1,897.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$1,897.88
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cash Price |
$1,511.70
|
| Rate for Payer: Cigna Commercial |
$4,821.32
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$1,897.88
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,932.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$1,897.88
|
| Rate for Payer: Health EOS Commercial |
$4,664.10
|
| Rate for Payer: HFN Commercial |
$4,821.32
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$7,060.10
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,897.88
|
| Rate for Payer: Independent Care Health Plan Medicare |
$1,897.88
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$1,897.88
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$1,897.88
|
| Rate for Payer: Multiplan Commercial |
$4,192.45
|
| Rate for Payer: NAPHCARE Commercial |
$2,846.81
|
| Rate for Payer: Preferred Network Access Commercial |
$4,821.32
|
| Rate for Payer: Quartz Beloit One Network |
$2,567.87
|
| Rate for Payer: Quartz Commercial |
$3,406.36
|
| Rate for Payer: Quartz Medicare Advantage |
$1,897.88
|
| Rate for Payer: The Alliance Commercial |
$7,591.50
|
| Rate for Payer: United Healthcare Medicare Advantage |
$1,897.88
|
| Rate for Payer: United Healthcare PPO |
$3,930.42
|
| Rate for Payer: WEA Trust Commercial |
$2,882.31
|
| Rate for Payer: Wellcare Medicare |
$1,897.88
|
| Rate for Payer: WPS Commercial |
$3,881.54
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$54,487.68
|
|
|
Service Code
|
MSDRG 584
|
| Min. Negotiated Rate |
$16,900.69 |
| Max. Negotiated Rate |
$54,487.68 |
| Rate for Payer: Aetna Managed Medicare |
$16,900.69
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$46,708.36
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$35,801.58
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$34,013.84
|
| Rate for Payer: Anthem Medicare Advantage |
$16,900.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$16,900.69
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$16,900.69
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$16,900.69
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$37,758.48
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$16,900.69
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$39,720.41
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$16,900.69
|
| Rate for Payer: Independent Care Health Plan Medicare |
$16,900.69
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$16,900.69
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$16,900.69
|
| Rate for Payer: NAPHCARE Commercial |
$25,351.03
|
| Rate for Payer: Quartz Medicare Advantage |
$16,900.69
|
| Rate for Payer: The Alliance Commercial |
$54,487.68
|
| Rate for Payer: United Healthcare Medicare Advantage |
$16,900.69
|
| Rate for Payer: United Healthcare PPO |
$30,922.85
|
| Rate for Payer: Wellcare Medicare |
$16,900.69
|
|
|
BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$46,894.64
|
|
|
Service Code
|
MSDRG 585
|
| Min. Negotiated Rate |
$15,280.21 |
| Max. Negotiated Rate |
$46,894.64 |
| Rate for Payer: Aetna Managed Medicare |
$15,280.21
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$42,091.42
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32,262.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$30,651.70
|
| Rate for Payer: Anthem Medicare Advantage |
$15,280.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$15,280.21
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$15,280.21
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$15,280.21
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$34,026.20
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$15,280.21
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$34,151.52
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$15,280.21
|
| Rate for Payer: Independent Care Health Plan Medicare |
$15,280.21
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$15,280.21
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$15,280.21
|
| Rate for Payer: NAPHCARE Commercial |
$22,920.32
|
| Rate for Payer: Quartz Medicare Advantage |
$15,280.21
|
| Rate for Payer: The Alliance Commercial |
$46,894.64
|
| Rate for Payer: United Healthcare Medicare Advantage |
$15,280.21
|
| Rate for Payer: United Healthcare PPO |
$26,587.39
|
| Rate for Payer: Wellcare Medicare |
$15,280.21
|
|
|
Breast Cancer Panel
|
Facility
|
IP
|
$1,482.00
|
|
|
Service Code
|
CPT 81433
|
| Hospital Charge Code |
4924642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$755.23 |
| Max. Negotiated Rate |
$1,417.98 |
| Rate for Payer: Aetna Commercial |
$1,387.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,325.50
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$816.88
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$1,417.98
|
| Rate for Payer: Health EOS Commercial |
$1,371.74
|
| Rate for Payer: HFN Commercial |
$1,417.98
|
| Rate for Payer: Multiplan Commercial |
$1,233.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,417.98
|
| Rate for Payer: Quartz Beloit One Network |
$755.23
|
| Rate for Payer: Quartz Commercial |
$924.77
|
| Rate for Payer: WEA Trust Commercial |
$847.70
|
| Rate for Payer: WPS Commercial |
$1,141.58
|
|
|
Breast Cancer Panel
|
Facility
|
OP
|
$1,482.00
|
|
|
Service Code
|
CPT 81433
|
| Hospital Charge Code |
4924642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$431.56 |
| Max. Negotiated Rate |
$1,711.83 |
| Rate for Payer: Aetna Commercial |
$1,387.15
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,325.50
|
| Rate for Payer: Aetna Managed Medicare |
$431.56
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,711.83
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$798.85
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$757.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$816.88
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$1,417.98
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$862.52
|
| Rate for Payer: Health EOS Commercial |
$1,371.74
|
| Rate for Payer: HFN Commercial |
$1,417.98
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,155.96
|
| Rate for Payer: Multiplan Commercial |
$1,233.02
|
| Rate for Payer: NAPHCARE Commercial |
$924.77
|
| Rate for Payer: Preferred Network Access Commercial |
$1,417.98
|
| Rate for Payer: Quartz Beloit One Network |
$755.23
|
| Rate for Payer: Quartz Commercial |
$1,001.83
|
| Rate for Payer: Quartz Medicare Advantage |
$924.77
|
| Rate for Payer: The Alliance Commercial |
$770.64
|
| Rate for Payer: United Healthcare PPO |
$1,155.96
|
| Rate for Payer: WEA Trust Commercial |
$847.70
|
| Rate for Payer: WPS Commercial |
$1,141.58
|
|
|
Breast Cancer Panel
|
Professional
|
Both
|
$1,482.00
|
|
|
Service Code
|
CPT 81433
|
| Hospital Charge Code |
4924642
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$678.16 |
| Max. Negotiated Rate |
$1,611.40 |
| Rate for Payer: Aetna Commercial |
$1,464.22
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,325.50
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cash Price |
$444.60
|
| Rate for Payer: Cigna Commercial |
$1,464.22
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$770.64
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$924.77
|
| Rate for Payer: Health EOS Commercial |
$1,402.56
|
| Rate for Payer: HFN Commercial |
$1,464.22
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,611.40
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$1,611.40
|
| Rate for Payer: Multiplan Commercial |
$1,233.02
|
| Rate for Payer: Preferred Network Access Commercial |
$1,464.22
|
| Rate for Payer: Quartz Beloit One Network |
$678.16
|
| Rate for Payer: Quartz Commercial |
$878.53
|
| Rate for Payer: The Alliance Commercial |
$770.64
|
| Rate for Payer: WEA Trust Commercial |
$847.70
|
| Rate for Payer: WPS Commercial |
$1,141.58
|
|
|
BREAST EXPANDERS PLACEMENT
|
Facility
|
IP
|
$3,935.00
|
|
| Hospital Charge Code |
2959878
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,005.28 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,455.44
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
|
BREAST EXPANDERS PLACEMENT
|
Facility
|
OP
|
$3,935.00
|
|
| Hospital Charge Code |
2959878
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,145.87 |
| Max. Negotiated Rate |
$3,765.01 |
| Rate for Payer: Aetna Commercial |
$3,683.16
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$3,519.46
|
| Rate for Payer: Aetna Managed Medicare |
$1,145.87
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$2,660.06
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$2,046.20
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$1,964.35
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$2,168.97
|
| Rate for Payer: Cash Price |
$1,180.50
|
| Rate for Payer: Cigna Commercial |
$3,765.01
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$2,290.17
|
| Rate for Payer: Health EOS Commercial |
$3,642.24
|
| Rate for Payer: HFN Commercial |
$3,765.01
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$3,069.30
|
| Rate for Payer: Multiplan Commercial |
$3,273.92
|
| Rate for Payer: NAPHCARE Commercial |
$2,455.44
|
| Rate for Payer: Preferred Network Access Commercial |
$3,765.01
|
| Rate for Payer: Quartz Beloit One Network |
$2,005.28
|
| Rate for Payer: Quartz Commercial |
$2,660.06
|
| Rate for Payer: Quartz Medicare Advantage |
$2,455.44
|
| Rate for Payer: The Alliance Commercial |
$2,046.20
|
| Rate for Payer: WEA Trust Commercial |
$2,250.82
|
| Rate for Payer: WPS Commercial |
$3,031.13
|
|
